The co-management of HIV and chronic non-communicable diseases in the Dominican Republic: A qualitative study

People living with HIV and a non-communicable disease (NCD) experience multi-level barriers when co-managing multiple conditions. We explored the factors affecting living with multiple chronic conditions in the Dominican Republic. We conducted 21 in-depth interviews from October 2019-February 2020 with Dominican adults who participated in a food security intervention and managed HIV and at least one chronic NCD. Using thematic analysis, we explored participant lived experiences co-managing multiple chronic conditions. All participants (mean age = 45.5 years) were linked to HIV care, but only three were linked to NCD-specific care. Individual-level barriers to managing NCDs included limited education and limited self-efficacy for self-management. Interpersonally, barriers included limited rapport building with an NCD-specific specialist. Structural barriers to managing NCDs were no health insurance, poor referral systems, and limited financial assistance. Health system adaptation requires equitably considering the needs of individuals managing multiple chronic conditions. Key factors to address include patient-provider relationships, improved referral systems, accessibility and availability of specialists, and financial assistance.


ProMeSA
End Line Semi-structured Interview Guide Introduction: Thank you for meeting with me today. Today we are speaking with people who have received medical care at this clinic who are managing HIV and other chronic conditions such as elevated blood sugar levels. We are also interested in understanding more about your experiences participating in the ProMeSA program, specifically with the urban gardens and nutritional education. Please do not worry about remembering all the details. What I am interested in are your experiences and reactions in general about the topics we will talk about today and there are no correct answers.
As I explained in the consent, I will ask you questions and some may be sensitive. If you feel uncomfortable with any question, we can skip it. All the information you share with me today is confidential, meaning that only members of the study team will have access to it. I would like to audio record this interview to be able to later transcribe the interview and ensure that we accurately capture your comments. Once we complete the transcription, we will destroy the audio recording (approximately January or February 2020). I would like to emphasize that nothing that we will talk about will affect your HIV care. I will be taking notes during the interview so that I can better remember what we spoke about and to help with interpretation. I will not include your name in these notes to keep it confidential. Do you have any general questions for me before we start?
(PAUSE, ALLOW TIME FOR QUESTIONS) I will start the recorder now. Tell me about the experiences you had with the urban gardens in the program [Clarify if the participant had a home garden, participated in a community garden, or did both or neither]. PROBES:

Participant Identification
• Which aspects of the garden program did you like?
• Which aspects of the garden program did you not like? 4.3 What were the barriers you experienced in starting and maintaining your garden?
• How useful were the gardening classes in helping you start a garden?
• How useful was the follow-up by the agronomist to your home in establishing and maintaining your garden? • What problems did you experience in having a garden (space, water, animals, diseases)? How were you able to resolve it, or not? • What were the facilitators in having a garden? What helped you? 4.5 Tell me about the experiences you had with the nutritional counseling in the program (nutritional counseling from Romelia and the cooking classes). PROBES: • What aspects of participating in nutritional counseling did you like?
• What aspects of participating in nutritional counseling did you not like? 5. 6 What were the barriers you faced in participating in nutritional education?
• What were the barriers for participating in the nutritional counseling in the SAI?
• What were the barriers for participating in the cooking workshops?
• How easy was it to apply your knowledge about nutrition and healthy cooking in your daily life? • What were the facilitators in helping you participate in the nutritional education and apply the lessons to your own life? 4.7 How easy or difficult was it to participate in the data collection process for ProMeSA? In other words, the survey, weight measures, height measures, blood draws, etc.?
• What changes do you suggest that we make to these measurements?
• Was it difficult to come back to the clinic to get a blood draw? 4.8 Do you have other comments to improve the program for future participants? o Grains? What changed in terms of the quantity of foods as compared to before starting the program?

5.2
Before enrolling in the program, did you have any problems getting the amount of food you wanted or needed for you and your family? PROBES: • Did you have problems getting the variety of foods that you needed or wanted? 5.3 Could you tell me about the skills and knowledge you gained during the program? PROBES: • In relation to having a garden?
• In relation to healthy eating?
• In relation to managing your HIV and/or other conditions? 5.4 In thinking about the last 12 months since you started participating in the program: Have you had any changes in your quality of life? PROBES: [If they said there were changes] • What do you attribute these changes in your quality of life to?
• What aspects of the program contributed to these changes?